Same-Same but Different: Young Women, Like Men, Report Chest Pain in Acute MI

Chest pain is the predominant symptom in young men and women presenting to the hospital with acute myocardial infarction, but women are more likely to also have additional warning signs such as epigastric symptoms, palpitations, and pain or discomfort in the jaw, neck, arms, or upper back, a new study shows. 

Slightly more than half of all hospitalized patients do not perceive their symptoms to be heart-related, although perceptions as to what the problem is differs between men and women, report investigators.

For example, more than one in five women in the study attributed their symptoms to stress or anxiety compared with just 12% of men, while men were more likely than women to think the pain was muscular.

The present study, lead investigator Judith Lichtman, PhD (Yale University, New Haven, CT), told TCTMD, is important as it documents the broad array of symptoms women experience in conjunction with chest pain. Chest pain in women, which is often described as pressure, tightness, and/or discomfort, may not exist in isolation from other symptoms, she said, and this may make it difficult for physicians to home in on acute MI.  

“I imagine for this population, where events are more rare, it may be more complicated when a younger woman comes in and talks about nausea, muscle pain, stress, or anxiety, and then lists some chest tightness at the very end,” said Lichtman. “I think the message is to listen carefully. Young women may present with multiple symptoms and that might be one of the challenges in identifying them.”

Go Red for Women

The study, published February 20, 2018, in Circulation as part of the American Heart Association’s Go Red for Women campaign, is based on direct patient interviews with 2,009 women and 976 men aged 18 to 55 years who were hospitalized with acute MI in the VIRGO study.

To TCTMD, Lichtman said VIRGO was designed to better understand why younger women with heart disease have a higher risk of dying from acute MI than similarly aged men. Given the worse outcomes, Lichtman and colleagues sought to determine if there were any differences in the recognition and presentation of acute MI symptoms between men and women, which might account for delays in seeking treatment. 

Overall, 87.0% of women and 89.5% of men presented to the hospital with chest pain, pressure, tightness, or discomfort. However, more than 61.0% of women also presented indigestion, nausea, or stomach pain and/or discomfort compared with just half of men. Nearly two-thirds of women, compared with 58.1% of men, had pain/discomfort in the jaw, neck, arms, or between the shoulder blades. Additionally, more women than men presented with three or more non-chest pain symptoms.

Lichtman explained that previous studies on symptom presentation have relied on chart review, with traditional chest pain symptoms tending to be more common in men compared with women. However, based on her previous research, Lichtman said women describe symptoms a little differently, referring not just to chest pain but also to chest pressure, tightness, or discomfort. By broadening the definition, the researchers here likely captured more women with chest pain and found the proportion of women with chest pain similar to that of men.

Of those studied, more than half of women and men did not attribute their symptoms to cardiac causes. Nearly two-thirds of all subjects sought care because the symptoms would not go away and more than half because the pain became too bad to ignore, but women were still less concerned the problem was related to their heart than men. Women tended to seek care because they were concerned about another condition, such as diabetes, rather than cardiac disease.

Ajay Kirtane, MD (Columbia University Medical Center, New York, NY), who was not involved in the study, said well-trained physicians are aware that women will present with more non-chest pain symptoms than men, but typical chest pain is still very predominant among women hospitalized with acute MI.

He praised the “descriptive” study for increasing education among physicians, and particularly among patients, about the range of symptoms that can be associated with acute MI. In the study, more than 10% of patients reported confusion, and if they are also having epigastric symptoms, “this is not something they’d associate with an MI,” Kirtane told TCTMD. “But it means our vigilance has to be high.” 

Kirtane also pointed out that among individuals who sought care in the week prior to hospital presentation, more than half of women said their medical providers did not think their symptoms were heart-related. For men who’d sought care in the week prior, 36.7% of healthcare providers did not think the symptoms were cardiac in nature.

In the outpatient setting, given the various demands on physicians’ time, taking a detailed history can be challenging, he said. However, for those who are able to do so, “a lot of time you can increase the specificity of your history and your clinical assessment by asking a broader range of questions and really pressing people on the types of symptoms they have,” Kirtane advised.

Clear Risks for Cardiovascular Disease

To TCTMD, Lichtman noted that while the men and women were young, they had clear risks for cardiovascular disease, including hypertension, high cholesterol levels, and a positive family history. Overall, women took more time from symptom onset to hospital presentation (3.2 hours vs 2.4 hours for men; P = 0.004). Nearly 40% of men took less than 2 hours from symptom onset to hospital presentation compared with just one-third of women (P = 0.002).

“From a clinical perspective, the women who came into hospital, as well as the men, had a clear risk factor profile,” she said. “Many had hypertension [or] diabetes, and more than 70% had a history of heart disease. If a patient has the combination of risk factors, particularly with a family history, it might be worth taking a closer look if you hear any of the symptoms that correspond to chest pain or pressure.”

Lichtman noted that among those with suspected symptoms of heart disease who had sought care prior to the hospitalization, there was no sex differences in early workups testing for cardiac problems.

In an editorial, Nanette Wenger, MD (Emory University School of Medicine, Atlanta, GA), points out that the “perception of risk,” particularly in this relatively young population, might partially explain the observed findings. For example, more than 40% of those surveyed did not consider themselves at risk for MI despite having a substantial burden of cardiovascular risk factors. Also, women did not appear to be as aware of non-chest pain symptoms.

“Although more than 50% of women identified chest pain as associated with acute myocardial infarction, few considered less traditional symptoms such as fatigue, nausea, and shortness of breath as warning symptoms, with awareness lower for younger than for older women,” she writes.

Additionally, “physicians must appreciate the importance of chest pain in the context of a greater number of non-chest pain symptoms among women,” namely because promptly recognizing acute MI may be delayed in such a scenario with adverse consequences, according to Wenger.